435202874-9-4-2026-26-AS-CKAI-DYE3GR-20260929181445

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202874
Report Date: 07/29/2026
Date Signed: 09/04/2026 03:11:28 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2025 and conducted by Evaluator Marcella Tarin

COMPLAINT CONTROL NUMBER: 26-AS-20250909093332

FACILITY NAME:	IVY PARK AT SAN TOMAS		FACILITY NUMBER:	435202874
ADMINISTRATOR:	PADILLA SANCHEZ, KENIA		FACILITY TYPE:	740
ADDRESS:	3930 WILLIAMS RD		TELEPHONE:	(669) 201-2015
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	82	CENSUS: 43	DATE:	07/29/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director (ED) Karen Nickolai		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not ensure that the resident's room was fully sanitized and disinfected after visibly being soiled with fecal matter.

INVESTIGATION FINDINGS:

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*This is an amendended report *
Licensing Program Analyst (LPA) Marcella Tarin conducted a complaint visit to deliver case findings. LPA met with Business Office Manager Maribel Abinsay and stated the purpose of the visit.

On 9/9/2025 the Department received a complaint with the above allegation. On 9/10/2025 the Department conducted the initial complaint investigation visit and obtained pertinent documentation.

It was alleged that on 9/3/2025 it was observed that a resident, referred to as R1, had feces smeared on the blinds, walls, bedding, doors and door handles throughout his/her room. Based on the reporting party (RP), R1’s mattress had no cover and was covered in dry urine and feces.

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250909093332

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 07/29/2026

NARRATIVE

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*This is an amended report*
RP stated this incident was reported to the Executive Director (ED) Karen Nickolai on 9/3/2025 and the ED assured that the mattress would be replaced, bed to be cleaned, and remaining feces would be cleaned up right away.

On 9/4/2025, the RP did a walkthrough of R1’s room with ED and observed there were areas that appeared to be 'untouched' as there were still feces on the door, door handles, chairs, and blinds, in addition to R1’s mattress still being dirty. RP stated the facility management blamed the resident for the issue.

On 05/26/2026, the Department conducted an additional interview with ED. Based on interview with the ED, the ED confirmed that the concerns of cleanliness of R1's room were brought to her attention in September 2025. ED stated it appeared to her that the feces had been in R1’s room for possibly a couple of days due to the feces being dry.

Based on staff interviews, 3 out of 4 staff stated that residents do have accidents with feces and urine. 4 Out of 4 staff stated housekeeping is notified when resident rooms have feces or urine, and housekeeping should be cleaning the rooms when these incidents occur.

Based on email correspondence, on 9/2/2025, Witness 1 (W1) informed RP that R1’s family sent an email to ED Karen Nickolai about R1’s room covered with feces. Email correspondence notes that the ED did not respond back to R1’s family regarding R1’s room being covered with feces. W1 stated R1 developed an eye infection due to the feces in the room coming into contact with R1's eye.

The review of R1’s records shows that R1 has bladder impairment and episodes of incontinence.

Based on photographs provided to the Department of the condition of R1’s bedroom on 09/02/2025 and 09/03/2025, it showed brown markings on the outer part of the toilet, brown markings above the toilet handle, brown marking on the floor in front of the toilet, large brown marking on the shower chair, brown markings on the shower curtain, brown spots on the wall, brown spots on two separate areas of the door, brown spots on the window blinds, and multiple large brown spots on R1’s bedding.

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SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20250909093332

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: IVY PARK AT SAN TOMAS	FACILITY NUMBER: 435202874
	VISIT DATE: 07/29/2026

NARRATIVE

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*This is an amended report*
The Department has investigated the above allegation. Based on interviews, records review and observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. A deficiency was cited per California Code of Regulations, Title 22, See LIC809 Case Management report on 07/17/2026 for the deficiency.

An exit interview was conducted with Business Office Manager Maribel Abinsay and a copy of this report was provided.

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END OF REPORT

SUPERVISORS NAME: Christine Kabariti
LICENSING EVALUATOR NAME: Marcella Tarin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026

LIC9099 (FAS) - (06/04)

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